Healthcare | Free Full-Text | Knowledge, Attitudes, and Practices of Parents in the Use of Antibiotics: A Case Study in a Mexican Indigenous Community
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The aim of this study was to analyse and determine whether there was a relationship between the KAP in an indigenous community whose first option was to use traditional medicine over antimicrobials.
Social Conditions Related to Bacterial Resistance Increase
In this study, half of the population lived in overcrowded conditions. Overall, 82.8% of those living in overcrowding have been ill at least once in the last six months, and 8.2% of them have been ill more than three times. This frequency is lower than that reported in other studies, which ranged from six to ten upper respiratory tract infections (URIs) per year [20,21,22]. Therefore, this population, which did not have a high number of diseases, did not use antibiotics more frequently than the rest of the population. The level of formal education in most of this population was lower than the national average (9.1 years). In this community, the population had a positive attitude towards antibiotic use, similarly to people with a higher level of education reported by other studies [23,24].
This situation shows that in this sample, social factors, including poverty, do not necessarily translate into a lack of protection against possible respiratory infections; on the contrary, poverty, lack of medical access, and cultural factors drive this population to use an ancestral alternative such as traditional medicine to treat conditions that, in other contexts, could be treated with antibiotics.
One of the crucial points of the proposals for the containment of bacterial resistance suggested by the WHO is to increase knowledge [25]. In this study, although a high percentage of the population recognized penicillin, amoxicillin, and metronidazole, only 2.32% of the population correctly identified most of the antibiotics included in the questionnaire. Therefore, the study confirms that this population has a low level of antimicrobial knowledge about antibiotics, as similarly shown in other studies. However, unlike Pavydė’s study, a low level of knowledge of antimicrobials was not associated with inappropriate behaviour [26].
In Mexico, since 2010, the sale of antibiotics with a medical prescription has been decreed in the official gazette of the federation. The aim was to reduce antibiotic consumption, and the emergence of clinics near pharmacies has been observed, along with a change in consumption patterns; however, this is notwithstanding the situation in rural areas.
In 2018, the mandatory implementation of the National Strategy for Action against Antimicrobial Resistance was declared. This strategy aims at establishing a program of evidence-based educational communication. For this purpose, in line with action, the level of knowledge of antimicrobial resistance should be estimated [27]. The interventions implemented in Mexico are directed at healthcare personnel [28], while for the general population, there are some informational pamphlets [29].
For example, in Greece, parents rarely request antibiotics [30]; however, in other contexts like Singapore, parents consider that antibiotics cure more quickly, and this is associated with the level of education [31]. On the other hand, in other Latin American communities, parents have little knowledge on the correct use of antibiotics, unlike the parents in this study [32].
Health beliefs lead this population to use ancestral treatments as a first choice that show no relationship with the increase in antibiotic resistance, generating a protective factor against antimicrobial resistance. Therefore, bacterial resistance should not be directly related to the lack of pharmacological knowledge of the population, but to more complex contextual factors, such as lack of access to healthcare services, poor medical prescription, lack of alternative treatments, health governance.
The positive attitude towards what the physician prescribes was not found to be related to socioeconomic conditions or knowledge about antibiotics, since most of the population did not agree to request antibiotics from physicians when it was unnecessary, demonstrating a positive attitude. This is similar to the results of a study conducted in Sweden, which showed that most of the respondents show an appropriate and restrictive attitude towards antibiotics [33]. The population has limited access to healthcare services as well as to the media, so they do not miss an antibiotic for their treatment, which has been used indiscriminately with the biomedical model, even as a prophylactic to prevent infections. An important behaviour conducive to bacterial resistance is self-medication and keeping antibiotics at home [34]. In this study, the lack of healthcare services did not lead to reported self-medication practices or storage of medicines at home. One-third effectively stated that they used some kind of home remedy to treat the flu, in the same way as reported in other regions of Mexico where healthcare services are lacking [35].
Since, in 80% of cases, respiratory tract infections are viral in nature, this makes the use of antibiotics for treatment unnecessary. This suggests that the use of antimicrobials only when necessary could be related to the low levels of antimicrobial resistance, as recommended by the WHO [36].
In areas with low accessibility to healthcare services, the practice of traditional medicine serves as an alternative to reduce the use of antibiotics [37]. As in the case of a viral infection, the use of traditional medicine contributes to the symptomatic care of respiratory conditions. This could result in the low presence of resistant bacteria compared to people who, for various reasons, make greater use of antibiotics, leading to bacteria with greater resistance. Therefore, the use of traditional medicine can be an example of an alternative treatment for the symptomatic control of viral respiratory diseases to reduce the unnecessary use of antimicrobials, mainly in viral infections, such as the use of aromatic plants in upper respiratory tract infection symptoms [38,39,40,41].
In our study, we recognize the importance of alternative models of healthcare provided by traditional healthcare institutions and healthcare professionals, not recognized by the biomedical model, where providers are as diverse as culture determines [42]. The use of traditional medicine is related to different causal phenomena, such as a lack of access to healthcare services and cultural customs [43]. The conditions of this study population have unintentionally led them to follow the recommendation of not using antibiotics indiscriminately.
Among the actions to manage antibiotic resistance is home care, avoiding the development of nosocomial infections that require excessive use of antibiotics. Doctors and nurses should adopt antimicrobial management strategies at home, utilizing digital tools or telemedicine, with new treatment opportunities and therapeutic choices [44,45,46].
Therefore, surveillance studies of resistant bacteria should be carried out locally with appropriate treatment guidelines in regions with health disparities and not be excessively influenced by reports from hospitals or different communities that stigmatize indigenous communities as having inappropriate behaviours regarding antibiotics and high levels of bacterial resistance. This misguided attitude could increase the utilization of high-spectrum antibiotics by healthcare personnel in empiric treatment, as low socioeconomic levels are usually equated with high levels of bacterial resistance. In fact, the use of traditional medicine could be a way to improve adequate behaviour with respect to the antibiotics used, especially topical remedies to treat symptomatology. Phyto-pharmacological studies show that medicinal plants that have been used for centuries have positive effects on the symptomatology used because these plants have been noted for their anti-inflammatory activity, antioxidants, antibacterial [47,48,49], or oregano (Origanum vulgare) tea to treat coughs, this plant have antimicrobial properties [50]. Other studies reported that this effect occurs through different mechanisms of action compared to those of antibiotics, with no specific targets [51].
Consequently, it seems to us that it is necessary to reconsider whether the behaviour of the population depends exclusively on variables such as the level of knowledge, attitudes, or practices. Should we analyse what kind of knowledge is required in the population? Do they need to recognize antibiotics or understand how to act when faced with an infection and how to use antibiotics correctly? This is important for targeting campaigns and not getting lost in ambiguities such as “increasing knowledge.” Restructure social indicators only if they make the community more prone to antibiotic use, which is the primary mechanism for generating and disseminating bacterial resistance. This finding has been demonstrated in various studies in public health [52,53]
A limitation to consider in the study is that the population is immersed in the PROSPERA social inclusion program where they must fulfil health responsibilities, that is, attend consultations and workshops to receive monetary support, so the responses could be influenced by belonging to this program [54]. Another limitation is related to the small size of the study sample, which, along with the particular characteristics of the local culture, makes the reported results not generalizable to the entire population but only locally impactful. The third limitation we can mention is related to the cross-sectional design of the study, which does not allow causality to be established. On the other hand, in this study, only the knowledge, attitudes, and practices reported by one of the parents of the children were obtained, not both; therefore, there could be differences between the knowledge, attitudes, or practices of both parents that could not be retrieved by this study.
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